Presentation Description

Comments

Presentation Transcript

POSTOPERATIVE PHYSICAL ASSESSMENT: ANESTHETIC CONSIDERATIONS IN THE PACU AND ICU and MODS:

POSTOPERATIVE PHYSICAL ASSESSMENT: ANESTHETIC CONSIDERATIONS IN THE PACU AND ICU and MODS Maribeth Massie, CRNA, MS, PhD(c) University of New England, MSNA Program

History of the PACU:

History of the PACU PACU has only been common for the past 50 years. 1920’s and 30’s: several PACU’s opened in the US and abroad It was not until after WW II that the number of PACU’s increased significantly; this was do to the shortage of nurses in the US In 1947 a study was released which showed that over an 11 year period, nearly half of the deaths that occurred during the first 24 hours after surgery were preventable 1949: having a PACU was considered a standard of care

PACU/ICU Location:

PACU/ICU Location Should be located close to the operating suite. Immediate access to x-ray, blood bank, blood gas and clinical labs Should have 1.5 PACU beds per operating room used. An open ward is optimal for patient observation with at least one isolation room Central nursing station Piped in oxygen, air, and vacuum for suction Requires good ventilation, because the exposure to waste anesthetic gases may be hazardous National Institute of Occupational Safety (NIOSH) has established recommended exposure limits of 25 ppm for nitrous and 2 ppm for volatile anesthetics

General considerations:

General considerations Most anesthetic recoveries are uneventful but complications do arise and can be sudden and life threatening Proximity to OR All emergency equipment available

Transport to the PACU/ICU:

Transport to the PACU/ICU CRNA at head of bed, close to patient’s airway HOB elevated ~ 30* or patient in lateral position to maximize airway patency O2 by FM or NC to counter hypoventilation and maximize oxygenation Monitor, especially if remains intubated to ICU or labile; bring emergency bag of drugs and intubating equipment Continually assess level of consciousness!

Level of Postoperative Care:

Level of Postoperative Care Choosing a post-anesthesia setting based on each patient’s need can reduce cost, enhance satisfaction, and optimize scarce PACU resources Fast tracking (Phase II) Local infiltration Minor blocks with sedation Major plexus anesthesia Use of short-acting anesthetics Biggest issues are with control of post-op pain and PONV

Discharge From the PACU:

Discharge From the PACU Aldrete Score: Simple sum of numerical values assigned to activity, respiration, circulation, consciousness, and oxygen saturation A score of 9 out of 10 shows readiness for discharge. Postanesthesia Discharge Scoring System (PADSS): Modification of the Aldrete score which also includes an assessment of pain, N/V, and surgical bleeding, in addition to vital signs and activity Also, a score of 9 or 10 shows readiness for discharge

Upper airway obstruction:

Upper airway obstruction:

Upper airway obstruction Total obstruction Lack of any air movement or breath sounds Chest retraction and diaphragmatic tugging are NOT signs of effective air movement MUST feel air with hand or ear over mouth  precordial stethoscope Partial obstruction Diminished tidal exchange associated with upper chest retraction and either snoring or inspiratory stridor

Treatment of upper airway obstruction:

Treatment of upper airway obstruction Soft tissue obstruction most common cause of upper airway obstruction Caused by relaxation of tongue and jaw Can also be caused by foreign body, dentures, tumors, infective process To relieve, place forefinger and second finger behind angle of mandible and exert forward pressure Can also extend neck to align airway axis